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Under the direction of the Care Management Manager, the Health Coach functions as the primary nurse to provide both health coaching and case management services to members across the continuum of health ranging from health promotion to end-of-life.
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FCHC has created a “one-stop shop” for patients–providing Pediatric and Adult Primary Care, Dental, OB/GYN and Women’s Health, Infectious Disease, Behavioral Health, Pharmacy, chronic disease education and care management, referral assistance, benefit enrollment assistance and coordination, and telehealth services.
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Consults with palliative care physician or designees as needed, informs primary physician of services provided and collaborate with other physicians as needed. Consults with palliative care physician or designees as needed, informs primary physician of services provided and collaborates with other physicians as needed.
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Assists in all facets of care coordination for palliative care referrals. The Nurse Practitioner, if providing palliative care, cares for patients facing chronic, complex, and/or life-threatening conditions at various locations within the flow of patient care.
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If providing Palliative Care: Minimum of five (5) years nursing experience required; clinical nursing care in oncology, hospice, geriatrics, intensive care preferred. Board Certification in Hospice and Palliative Care is preferred, but not required.
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Collaborating with the interdisciplinary team, the Primary Care Provider conducts assessments, develops care plans, and ensures continuity of care for participants. Oversee care coordination and review outcomes data for policy improvements.
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Responsible for clinical care coordination between the employees’ workers comp provider, Human Resources, and their primary care provider. Work with the Site Safety Coordinator when recommending referrals to a primary care provider, clinic, or hospital for any cases that require more attention than first aid care.
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Performs routine and emergency assessments related to outpatient palliative care visits. S/he provides assessments, disease and treatment education, and symptom management to meet the needs of palliative care patients and their families.
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The RN Case Manager facilitates care coordination and navigation through a complex healthcare system. The position requires the ability to work with and communicate with a variety of clinicians, including the care coordinator's assigned psychiatric providers, other clinicians within BHIP, the Mental Health Service, and primary care.
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The primary focus of early intervention is to provide education, training, and support to families to help their children learn and grow. Provide service coordination to assigned caseload including coordinating the development, monitoring, and review of the Individual Family Service Plan.
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S/he provides assessments, disease and treatment education, and symptom management to meet the needs to palliative care patients and their families. Assists in development of clinical practice guidelines/standards in support of quality palliative care.
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The RN works independently and as part of the Care Coordination team with the primary care providers and their patients at the Corvallis Clinic Asbury Building. Meets weekly with select primary care teams to review hospitalization and ED use, care coordination for high-risk patients, quality data, and to educate about new initiatives.
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Assist the provider/team with various care coordination activities. Responsible for collaborating with the primary advanced practice clinician, (APC) and facility to identify and respond to patient change in condition.
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Performs bedside palliative care patient/family evaluation in the patient’s place of residence. Performs bedside palliative care with patient/family education. The Nurse Practitioner, if providing hospice care, functions as an extension of the interdisciplinary team (IDT) and hospice physician to provide routine recertification and emergency assessments, educational, and evaluative services to meet the needs of patients and their families.
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If providing Hospice Care: Minimum of one (1) year nursing practice or equivalent experience required; hospice, oncology, or home health and/or long-term care preferred. S/he provides care and support in collaboration with the PCP and specialists; and ensures compliance with practice standards and codes.
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